Atrial fibrillation and advanced age

Transcription

1 Atrial fibrillation and advanced age Prof. Fiorenzo Gaita Director of the Cardiology School University of Turin, Italy

2 Prevalence of AF in the general population Prevalence and age distribution in patients with atrial fibrillation Projected number of adult with AF in the USA between % > 70 years of age >80 Framingham Study Western Australia Study Mayo Clinic Study Cardiovascular Health Study Feinberg WM et al. Arch Intern Med 1995;155: Go AS et al. JAMA 2001;285: (ATRIA Study)

3 Ederly AF patients are different from Younger - Atrial substrate modifications related to senescence - Problematic OAT managing Anticoagulation Paradox Röcken et al; Circulation 2002; Antiarrhythmic theraphy is more difficult to manage Altered liver and renal complications function, Prevention electrolyte abnormalities, pharmacological interactions, poor compliance pro-arrhythmias Ischemic Stroke hemorrhagic Burton et al J CV Risk 2001 Dayer et al. Am J Geriatr Cardiol 2002

4 - More comorbidities, associated diseases particularly SSS Pathologic recovery time of sinus node (increased by ADDs therapy)

5 Ederly AF patients are different from Younger but, above all, they are different from each others 83 y 80 y 84 y 82 y 95 y 84 y

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7 Clinical Case Retired Surgeon, 85 yr, marathon runner -Symptomatic Paroxysmal AF with rapid ventricular rate -Sinus bradycardia -Hypertension -Impaired renal function What could you do? a. AADs + OAC b. Rate control therapy + OAC c. AADs + LA appendage closure d. Rate control therapy + LAA closure e. PM+ AADs + OAC f. PM +AV node abl+ OAC g. PM + AVnode abl + LA appendage closure h. Afib ablation + strictly SR monitorization (Loop Recorder) i. Afib ablation + LA appendage closure

8 CHA 2 DS 2 VASc Choice of anticoagulant RISK FACTORS SCORE Congestive HF/ LV disfunction Hypertension 1 Age *major risk factor Diabetes mellitus 1 Stroke/TIA/ thromboembolism 2* major risk factor Vascular disease 1 Age CHA2DS2VASC TE risk ranging from 3.2-6%/y Sex category (f) 1 ESC AF Guidelines Update of the ESC AF Guidelines

9 CHA 2 DS 2 VASc RISK FACTORS Congestive HF/ LV disfunction SCORE Hypertension 1 Age *major risk factor Diabetes mellitus 1 Stroke/TIA/ thromboembolism 2* major risk factor Vascular disease 1 Age Sex category (f) 1 HAS-BLED RISK FACTORS SCORE Hypertension 1 Abnormal renal and liver function (1 point each) 1 or 2 Stroke 1 Bleeding 1 Labile INRs 1 Elderly (age> 65 y) 1 HASBLED 3 Drugs or alcohol 1 or 2 Hemorragic (1 point each) risk 3.8%/y ESC AF Guidelines 2010

10 Annual Thromboembolic Risk in pts with non valvular AF Treated with Warfarin or New Oral Anticoagulants % Stroke/year in Warfarin % Stroke/year in New Oral Anticoagulants 2.4% 2.1% 1.71% 1.6% 1.11% 1.27% CHADS CHADS CHADS 2 2.1

11 Annual Hemorragic Complications in pts with non valvular AF Treated with Warfarin or New Oral Anticoagulants % Major Bleeding/year in Warfarin % Major Bleedings/year in New Oral Anticoagulants 3.6% 3.4% 3.36% 3.09% 3.31% 2.13%

12 LAA and thromboembolic risk Incidence of thrombus in LAA reaches up to 91% Odell JA et al. Ann Thorac Surg 1996;61:565 9

13 Chickenwing type LAA, 451 (48%) pts Cactus type LAA, 278 (30%) pts LA appendage morphology and thromboembolic risk Non-CHKWING CHKWING 4,6% Windsock type LAA, 179 (19%) pts Cauliflower type LAA, 24 (3%) pts OR 6.49 (95% C.I ) 0,7% Gaita F. et al. JACC 2012;60:531-8

14 LA appendage closure

15 LA appendage Closure devices Amplatzer Watchman

16 PROTECT-AF: 707 pts M 70%, 72 y, 36% permanent AF, 38% previous stroke/tia 463 percutaneous LAA closure vs 244 Warfarin (INR 2-3) Holmes DR et al. Lancet 2009

17 PROTECT-AF: 707 pts M 70%, 72 y, 36% permanent AF, 38% previous stroke/tia 463 percutaneous LAA closure vs 244 Warfarin (INR 2-3) Holmes DR et al. Lancet 2009

18 Updated ESC guidelines Eur Heart J 2012

19 AFFIRM: Total Mortality (at 5 years) Rate control vs Rhythm control Rate control therapy vs Rhythm control therapy -70.8% Hypertension -38.2% Ischemic - EF 26% - Left atrium 64,7% Rhythm control Therapy (Antiarrhythmic drugs) Rate control Therapy Mean FU: 3,5 y New Engl. J. Med 2002;347:

20 AF therapy in the Elderly No difference in term of mortality, compared to SR maintenance RATE CONTROL THERAPY Easily achieved in persistent AF β-blockers simpler to manage than AADs Avoids proarrhythmic effects of AADs..but our patient had Paroxysmal AF and Sinus Bradycardia

21 AFFIRM: On treatment analysis in a subgroup of 2796 pts Covariates associated to survival: Covariate p HR Sinus Rhythm < Warfarin < RS e Warfarin of about 50% risk of death AADs Digoxin AADs and digoxin of about 50% risk of death Circulation 2004; 109:1509

22 New Therapies for SR maintenance 2010: Dronedarone

23 ATHENA TRIAL 4500 patients with paroxysmal (75%) / persistent AF (25%) Inclusion criteria: age 75 years or 70 years with 1 risk factor: hypertension; diabetes; prior stroke/tia; LA 50 mm; LVEF 0.40 Dronedarone 400 mg BID vs Placebo N Engl J Med 2009;360:668-78

24 Primary Endpoint Time to first cardiovascular hospitalization or death Mean Follow-up 21 ± 5 months RRR 24% RRA 7% 917 (39%) 734 (32%) N Engl J Med 2009;360:668-78

25 ATHENA Substudy: Analysis of Stroke 5 4 RRR: 34% RRA: 0.6% Mean follow-up 21 ± 5 months Placebo 70/2327 (1.8%) events (%) 3 2 Dronedarone 46/2301 (1.2%) mos Pz a rischio Placebo Dronedarone ATHENA. Circulation 2009;120:

26 ATHENA TRIAL 4500 patients with paroxysmal (75%) / persistent AF (25%) Inclusion criteria: age 75 years or 70 years with 1 risk factor: hypertension; diabetes; prior stroke/tia; LA 50 mm; LVEF 0.40 Dronedarone 400 mg BID vs Placebo Exclusion criteria: Sinus-node disease, bradycardia (HR < 50 bpm) PR > 0.28 sec, GFR < 10 ml/min; K < 3.5 mmol/l N Engl J Med 2009;360:668-78

27 In case of SSS, of about 30% of patients need PM implant The preferred stimulation is AAI Permanent transvenous Atrial Pacing: an experimental and clinical study Smyth N.P.D. et al ann Thorac Surg 1971;11: DANISH STUDY Lancet 1994;344: Lancet 1997;350:

28 Atrial Fibrillation 225 pts, age 76 y with SSS Atrial pacing (104 pts) vs Ventricular pacing (115 pts) 46% RRR Lancet 1997; 350:

29 1181 patients with symptomatic and medically refractory AF Qol LV function, Healtcare Use NYHA Exercise duration, heart rate Ablation ad pacing therapy improves a broad range of clinical outcomes for patients with AF. The calculated 1-year mortality rates (6.3%) are low and comparable with medical therapy Wood MA et al. Circulation 2000;101:

30 Why don t try Afib ablation in the Elederly?

31 EFFICACY of AF Ablation in the Elderly: 7 retrospective studies 434 pts > 70 years / 3935 total population (11%) Success (%) PVI PVI + Linear lesions PVI+ Focal abl PVI + Linear lesions PVI PVI ± Linear lesions PVI ± Linear lesions ~ 80% Mean FU 14 mos 24 pts 25 pts 32 pts 174 pts 83 pts 61 pts 35 pts Oral et al Circ 2004 Hsu et al Hearth R Zado JCE 2008 Corrado JCE 2008 Spragg JCE 2008 Kusumoto JICE 2009 Bunch PACE 2010

32 SAFETY of AF Ablation in the Elderly: 7 retrospective studies 434 pts > 70 years / 3935 total population (11%) ~ 80% Complications (%) 434 pts (11%of total population) with or w/o drugs One or more procedures ~ 4.5% Mean FU 14 mos 24 pts 25 pts 32 pts 174 pts 83 pts 61 pts 35 pts Oral et al Circ 2004 Hsu et al Hearth R Zado JCE 2008 Corrado JCE 2008 Spragg JCE 2008 Kusumoto JICE 2009 Bunch PACE 2010

33 Efficacy and Safety of Afib ablation at Long-term follow up stratified for age (paroxysmal and persistent AF) 887 pts, 1241 procedures (Jan 2001 and Jan 2009) 30% REDO PROCEDURES 78% 76% 77% Mean FU 65 mos ± 19 1,7% 0.7% 132 pts 614 pts 141 pts 4% Success Complications Gaita F. et al. 2012, Submitted

34 Long -term efficacy and safety of ablation compared to AADs in elderly patients with AF 344 pts age > 70 y 118 ABLATION (Group A) vs 226 AADs + ECV (Group B) 77% Success Late Complications 48% Mean FU 65 mos ± 19 8% 16% Gaita F. et al Europace 2012

35 Long-term adverse events (> 30 days) Ablation 118 pts (%) AADs+ ECV 226 pts (%) Death (CV causes) 2 (1.7) 5 (2) ns Stroke/TIA 3 (2.5) 2 (0.8) ns Peripheral Embolism 1 (0.8) 1 (0.4) ns Myocardial infarction 0 2 (0.8) ns Major Bleedings 1 (0.8) 2 (0.8) ns Minor Bleedings 1 (0.8) 10 (4) ns SSS worsening Pacemaker implant Safety: Long-term adverse events 2 (1.7) 0 15 (8) 5 p Gaita F. et al. Europace 2012

36 Comparison on QoL (SF-36) at basal and follow up Ablation postablation Basal Gaita F. et al. Europace 2012

37 -Female -78 y CHA 2 DS 2 VASC 3 + Atrial Fibrillation = Oral Anticoagulation If we restore and maintain SR after Afib ablation, what about oral anticoagulation?

38 3355 pts, OFF-OAT 2692 pts (80%), ON-OAT 663 pts (20%) 2% Mean FU 28±13 mos 0.45% 0.07% 0.04% Themistoclakis S. et al. JACC 2010

39 The principal answers were 85 yr, marathon runner Symptomatic Paroxysmal AF and Sinus bradycardia, CHA 2 DS 2 VASC 3, HASBLEED 3 AV Node Ablation+ PM+LA appendage closure Afib Ablation+Loop Recorder ±LA appendage Closure (in case of recurrences )